Behavioral Health Medical Director

Centene Corporation•Remote-TX, TX

1d•$236,500 - $449,300•Hybrid

About The Position

Centene is seeking a full-time Behavioral Health Medical Director for its Texas market. This role is part of the Medical Management/Health Services team and offers a fresh perspective on workplace flexibility. The Behavioral Health Medical Director will assist the Chief Medical Director in directing and coordinating medical management, quality improvement, and credentialing functions. This position provides medical leadership for utilization management, cost containment, and medical quality improvement activities. The role involves performing medical reviews for utilization, quality assurance, and complex medical services to ensure timely and quality decision-making. It also supports the implementation of performance improvement initiatives for capitated providers and assists in planning goals and policies to enhance care quality and cost-effectiveness. The Behavioral Health Medical Director will ensure compliance with regulatory, state, corporate, and accreditation requirements for quality improvement and utilization management programs. Additionally, this role assists the Chief Medical Director in the functioning of physician committees, conducts rounds for high-risk patients, and collaborates with clinical teams, providers, and consultants on complex cases and appeals. The position may also participate in provider network development and market expansion, assist in developing physician education, identify utilization review studies, and evaluate adverse trends. It involves reviewing claims for medical necessity and appropriate payment, developing provider alliances, and potentially representing the business unit on medical philosophy and policies. The role may require working weekends and holidays as needed.

Requirements

Medical Doctor or Doctor of Osteopathy.
Actively practices medicine.
Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services.
For Behavioral Health only - Board certification by the American Board of Psychiatry and Neurology.
Current Texas state license as a MD or DO without restrictions, limitations, or sanctions from government programs.
Current state medical license without restrictions.

Nice To Haves

Utilization Management experience and knowledge of quality accreditation standards preferred.
Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.
Experience treating or managing care for a culturally diverse population preferred.

Responsibilities

Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.
Provide medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.
Support effective implementation of performance improvement initiatives for capitated providers.
Assist Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
Provide medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
Assist the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.
Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
Collaborate effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
Participate in provider network development and new market expansion as appropriate.
Assist in the development and implementation of physician education with respect to clinical issues and policies.
Identify utilization review studies and evaluate adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
Identify clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
Interface with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.
Review claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
Develop alliances with the provider community through the development and implementation of the medical management programs.
As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.
Represent the business unit at appropriate state committees and other ad hoc committees.